MISCELLANEOUS Patient-reported Goal Achievement after Treating Male Benign Prostatic Hyperplasia with Alpha- adrenergic Antagonist: A -12week Prospective Multicenter Study Bum Soo Kim1, Tae-Hwan Kim1, Ki Ho Kim2, Byung Hoon Kim3, Ji Yong Ha3, Deok Hyun Cho4, Gun Nam Kim4, Yoon Hyung Lee5, Jae Soo Kim5, Hyun-Jin Jung6, Hong Seok Shin6, Phil Hyun Song7, Jong Hyun Yoon8, Jae Ho Kim8, Eun Sang Yoo1* Purpose: The study was designed to assess and predict patient-reported goal achievement after treatment of benign prostatic hyperplasia (BPH) patients with tamsulosin. Materials and methods: From November 2013 to October 2015, 272 patients initially diagnosed with BPH were prospectively enrolled in nine different centers. Before the treatment, subjective final goals were recorded by all patients. Every four weeks, the treatment outcomes were evaluated using international prostate symptom score (IPSS) and uroflowmetry, and adverse events were recorded. Patient-reported goal achievements were assessed after 12 weeks of treatment. Results: Of the enrolled patients, 179 patients completed the study. The pretreatment patients’ goals included the frequency improvement, nocturia improvement, residual urine sense improvement, well voiding, hesitancy improvement, weak urine stream improvement, urgency improvement, and voiding-related discomfort improve- ment. Of the 179 patients, 129 patients (72.1%) reported that they achieved their primary goals after three months of medical therapy. Logistic regression analysis revealed that pretreatment quality of life (OR = 8.621, 95% CI: 2.154-9.834), and improvement of quality of life (OR = 6.740, 95% CI: 1.908-11.490) were independent predictors of patient-reported goal achievement after tamsulosin monotherapy. Conclusion: Overall patient-reported goal achievement after medical therapy for BPH was high and the scores of pretreatment quality of life and improvement of quality of life can be important factors to predict the achievement of treatment goals. Keywords: prostatic hyperplasia; adrenergic alpha-antagonists; drug therapy; lower urinary tract symptoms; pa- tient outcome assessment INTRODUCTION Benign prostatic hyperplasia (BPH) is a common disease, which is present in 50% of men older than 50 years and in approximately 80% of men 80 years of age or older.(1,2) Lower urinary tract symptoms (LUTS) are the most common and bothersome problems of BPH. The LUTS due to BPH include hesitancy, a weak urine stream, incomplete voiding, frequent urination, nocturia, and urgency. In the past, LUTS due to BPH were usually managed by catheterization or surgery. However, over the past several decades, the manage- ment concept for BPH has transitioned from an acute 1 Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea. 2 Department of Urology, College of Medicine, Dongguk University, Gyeongju, Korea. 3 Department of Urology, College of Medicine, Keimyung University, Daegu, Korea. 4 Department of Urology, Gumi CHA Medical Center, Cha University, Gumi, Korea. 5 Department of Urology, Daegu Fatima Hospital, Daegu, Korea. 6 Department of Urology, Daegu Catholic University Medical Center, Daegu, Korea. 7 Department of Urology, College of Medicine, Yeungnam University, Daegu, Korea. 8 Department of Urology, Soonchunhyang University Gumi Hospital, Gumi, Korea. *Correspondence: Department of Urology, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, Korea Postal code: 41944 Telephone: +82 53 200 5845. FAX: +82 53 421 9618. E-mail: uroyoo@knu.ac.kr. Received December 2016 & Accepted December 2017 surgical condition to a chronic medical condition.(3) The development of alpha-adrenergic blockers (α-blockers) changed the treatment patterns of BPH. It has been reported that most patients who were newly diagnosed with BPH in the USA underwent watchful waiting or medical therapy, and monotherapy with α-blockers was the most common first-line medical therapy, constituting about 80% of the treatments.(4) The physiological function of α-blockers is the relax- ation of smooth muscles in the prostate and bladder neck, thereby reducing the resistance to urinary flow and improving LUTS. First-generation α-blockers Urology Journal/Vol 16 No. 4/ July-August 2019/ pp. 386-391. [DOI: http://dx.doi.org/10.22037/uj.v0i0.3784] were non-selective agents, and their use was associated with frequent cardiovascular and gastrointestinal side effects. Second-generation α-blockers, including tera- zosin and doxazosin, showed reduced side effects but required dose titration due to various vascular sequelae, such as hypotension, dizziness, fainting, and postural hypotension. More recently, third-generation α-block- ers, including tamsulosin, alfuzosin, and silodosin, have been developed, which have a high affinity and selec- tivity for alpha-1A adrenergic receptors in the prostate and a lower affinity for the receptors in blood vessels. Currently, these agents are widely used for the medical therapy of BPH and have been reported to effectively improve LUTS with a low risk of vascular side effects.(5) Tamsulosin, which is one of the most popular α-block- ers, is an alpha-1A and alpha-1D selective adrenocep- tor antagonist, and its efficacy and safety have been well established in many studies.(6-10) Several clinical tools, such as the International Prostate Symptom Score (IPSS), American Urological Association Symptom Score (AUASS), peak flow rate (Qmax), and post-void residual urine (PVR), have been used to evaluate the improvement of LUTS in BPH patients. Although these tools have been considered good measurement indi- ces, it is still difficult to assess patients’ treatment goal achievement using these tools. Therefore, we tried to evaluate the patients’ goal achievement with medical therapy for BPH and performed a prospective multi- center study to assess and predict the patient-reported goal achievement after treatment with tamsulosin. MATERIALS AND METHODS Study design and sample size From November 2013 to October 2015, 272 patients initially diagnosed with BPH were prospectively en- rolled in nine different centers (at least 30 patients in each center). All patients were informed about the pur- pose and protocol of this study and provided consent. This study was approved by the Institutional Review Board of each hospital (No. 2013-12-022). The primary endpoint of this study was the score of the patient-re- ported goal achievement after 12 weeks of treatment, and the secondary endpoints were the changes of the total IPSS, voiding subscore, storage subscore, quality of life (QoL), Qmax, and PVR at 4, 8, and 12 weeks of treatment compared to the baseline. Study population The inclusion criteria of this study were as follows: male patients with the age of 40 years or older, a base- line total IPSS of ≥ 8, a bother score of QoL of ≥ 3, ini- tially diagnosed patients with BPH without a history of prior ≥-blocker medication for the recent 12 weeks and no history of prior 5-alpha-reductase inhibitor (5-ARI) medication for the recent 12 weeks. Patients requiring surgery, those with suspicious hypersensitivity or a con- traindication for ≥-blockers, a prior history of prostatic surgery, moderate or severe liver or renal function im- pairment, moderate or severe cardiovascular disorder, postural hypotension, hypotension, a history of senile dementia, combined urinary tract infection, underlying neurological disease, underlying urogenital malignan- cy, urethral stricture, chronic prostatitis or chronic pel- vic pain syndrome, and serum prostate-specific antigen (PSA) of ≥ 4 ng/mL were excluded from this study. Variables and follow up period Before the treatment, all patients underwent medical history taking, physical examination, including blood pressure and digital rectal examination, a serum PSA test, urinalysis with urine culture, transrectal ultrasound, uroflowmetry, and IPSS with QoL determination. In addition, all patients were asked about their subjective final goals of treatment for BPH. Since tamsulosin 0.2 mg is recommend as initial treatment dose in East Asian patients with BPH, tamsulosin was initiated at 0.2 mg once daily, and the treatment continued for 12 weeks. After four weeks of treatment, if the parameters of uro- flowmetry or IPSS were not improved, or patients were not satisfied with their voiding status, the dose of tam- sulosin was escalated up to 0.4 mg. Other medications that could affect patients’ LUTS, such as cholinergic drugs, anticholinergic drugs, 5-ARIs, desmopressins, and other ≥-blockers, were not permitted throughout the study period. Every four weeks, the treatment out- comes were evaluated using IPSS and uroflowmetry, and adverse events were recorded. After 12 weeks of treatment, patient-reported goal achievements were as- sessed. The scoring of the goal achievement was set by 1 (completely unachieved), 2 (unachieved), 3 (neither achieved nor unachieved), 4 (achieved), and 5 (com- pletely achieved). In addition, all patients were divided into two groups according to the goal according score; lower score (1, 2 and 3) and higher score (4 and 5), and risk factors for lower score of goal achievement were assessed using logistic regression analysis. Statistical methods Statistical analyses were performed using SPSS 18.0 (SPSS, Chicago, IL, USA). Continuous variables, such as IPSS, QoL score, Qmax and PVR were compared by Student’s t-test and these variables of each time point (0, 4, 8 and 12 weeks) were compared by one-way anal- ysis of variance (ANOVA). When the value was found to be significant after an assessment using the ANOVA statistical test, the Tukey’s post-hoc comparison was performed. Univariate and multivariate analyses were performed to determine the risk factors for tamsulosin dose escalation and lower score of patient-reported goal achievement. A P value of less than 0.05 was consid- ered statistically significant. RESULTS Of the enrolled patients, 179 patients completed the Goal achievement for management of BPH-Kim et al. Table 1. Baseline patients’ characteristics. Characteristics Valuesa No. of patients 179 Mean age (years) 62.0 ± 8.4 Mean serum PSA (ng/mL) 1.7 ± 2.6 Mean prostate volume (g) 31.7 ± 12.2 Patients’ goal setting Nocturia improvement (n = 63) WUS improvement (n = 52) Frequency improvement (n = 34) RUS improvement (n = 27) Hesitancy improvement (n = 22) Well voiding (n = 21) Urgency improvement (n = 11) Voiding related discomfort improvement (n = 2) a Data are presented as mean±SD or number Abbreiations: PSA, prostate-specific antigen; RUS, residual urine sense; WUS, weak urine stream Miscellaneus 387 Vol 16 No 04 July-August 2019 388 study and reported their goal achievement score after 12 weeks of tamsulosin monotherapy. The reasons for dropping out of the study included a treatment failure (n = 14), adverse events (n = 6), a follow-up loss (n = 65), and PSA elevation (n = 8). The adverse events that occurred in the dropped-out patients were one case of each dizziness, fever, vomiting, and general weakness and two cases of ejaculatory disorders. The mean age, mean serum PSA level, and mean prostate size of the patients who completed the study are recorded in Table 1. Of the 179 patients, 42 patients set multiple goals (32 patients with 2 goals, 9 patients with 3 goals and 1 patient with 4 goals) and the goals set by the patients included the nocturia improvement (n = 63), weak urine stream improvement (n = 52), frequency improvement (n = 34), residual urine sense improvement (n = 27), hesitancy improvement (n = 22), well voiding (n = 21), urgency improvement (n = 11), and voiding-related dis- comfort improvement (n = 2). After four weeks of treatment, the mean Qmax, and total IPSS values, as well as the mean QoL score, sig- nificantly improved, and the tamsulosin dose was esca- lated to 0.4 mg for 74 patients. The logistic regression analysis showed that less improvement in Qmax [odds ratio (OR) = 1.1, 95% confidence interval (CI): 1.0–1.2, P = .043] and that in PVR (OR = 1.0, 95% CI: 1.0–1.0, P = .017) were independent risk factors for tamsulosin dose escalation. After 8 and 12 weeks of treatment, all the parameters further improved (Table 2). After 12 weeks of treatment, the scores of patient-reported goal achievements were as follows: 5 in 21 patients (11.7%), 4 in 108 patients (60.3%), 3 in 33 patients (18.4%), 2 in 7 patients (3.9%), and 1 in 10 patients (5.6%). Higher score group had shorter mean duration of LUTS (16.4 vs 36.6 months, P = .002), lower pretreatment total IPSS (15.7 vs 18.6, P = .017), lower pretreatment IPSS voiding subscore (9.3 vs 11.4, P = .014), and lower pre- treatment QoL score (3.8 vs 4.1, P = .028) than lower score group. Post-treatment total, voiding and storage subscores of IPSS and QoL were also significantly low- er in higher score group compared to lower score group. Improvement of total, voiding and storage subscores of IPSS and QoL were significantly higher in higher score group. However, mean age, mean PSA level, mean Table 2. Changes in symptom scores including quality of life and uroflowmetric parameters after 12 weeks treatment of tamsulosin. Variablesa Baseline 4-week Treatment 8-week Treatment 12-week Treatment P valueb IPSS (total) 17.5 ± 7.0 13.6 ± 6.7 12.5±6.4 11.0 ± 6.4 < 0.001 Voiding subscore 10.4 ± 4.8 7.9 ± 4.4 7.4 ± 4.1 6.2 ± 4.1 < 0.001 Storage subscore 6.9 ± 3.4 5.7 ± 3.2 5.2 ± 2.9 4.8 ± 2.9 0.001 QoL 4.0 ± 1.0 3.1 ± 1.2 2.8 ± 1.2 2.5 ± 1.2 < 0.001 Qmax (ml/sec) 12.5 ± 5.8 14.8 ± 6.4 15.3 ± 5.2 16.3 ± 5.8 0.001 PVR (ml) 36.5 ± 55.0 27.5 ± 43.7c 26.8 ± 44.7c 17.9 ± 26.7 < 0.001 a Data are presented as mean ± SD or number a Continuous variables were compared by independent samples t-test b P value was determined by ANOVA test c These values were not statistically different compared with that of baseline by Tukey’s post-hoc analysis (P > 0.05) Abbreviations: IPSS, international prostate symptom score; QoL, quality of life; Qmax, peak flow rate; PVR, post-void residual urine Table 3. Comparisons of demographic, medical and voiding characteristics between higher and lower score groups. Variablesa Higher score (n=129) Lower score (n=50) P value Age (years) 60.1 ± 8.3 62.6 ± 7.1 0.063 Duration of LUTS (months) 16.4 ± 23.4 36.6 ± 43.8 0.002 Prostate volume (g) 32.3 ± 10.4 33.0 ± 13.0 0.745 PSA (ng/ml) 1.6 ± 2.0 1.8 ± 1.8 0.688 Pretreatment Qmax (ml/s) 13.4 ± 6.4 11.8 ± 5.3 0.142 Pretreatment PVR (ml) 30.3 ± 51.9 35.3 ± 40.7 0.537 Pretreatment IPSS (total) 15.7 ± 6.4 18.6 ± 6.9 0.017 Pretreatment IPSS (voiding) 9.3 ± 4.2 11.4 ± 5.4 0.014 Pretreatment IPSS (storage) 6.3 ± 3.3 7.1 ± 3.6 0.198 Pretreatment QoL 3.8 ± 0.9 4.1 ± 0.8 0.028 No. of goals 1.3 1.4 0.096 Posttreatment Qmax (ml/s) 15.6 ± 6.0 14.2 ± 6.9 0.252 Posttreatment PVR (ml) 22.3 ± 33.9 25.7 ± 24.8 0.509 Posttreatment IPSS (total) 11.5 ± 5.9 15.8 ± 6.7 < 0.001 Posttreatment IPSS (voiding) 6.7 ± 3.8 9.3 ± 4.6 < 0.001 Posttreatment IPSS (storage) 4.8 ± 2.7 6.5 ± 3.5 0.002 Posttreatment QoL 2.6 ± 1.1 3.7 ± 1.0 < 0.001 Δ Qmax (ml/s) 3.9 ± 5.1 3.5 ± 6.3 0.754 Δ PVR (ml) -12.9 ± 42.1 -18.8 ± 37.3 0.447 Δ IPSS (total) -7.2 ± 5.6 -2.9 ± 6.1 < 0.001 Δ IPSS (voiding) -4.7 ± 3.9 -2.3 ± 4.9 0.006 Δ IPSS (storage) -2.6 ± 2.6 -1.2 ± 2.8 0.007 Δ QoL -1.9 ± 1.2 -0.6 ± 1.1 < 0.001 Cases of dose escalation 40 (31.0%) 19 (38.0%) 0.103 a Data are presented as mean ± SD or number Abbreviations: LUTS, lower urinary tract symptoms; PSA, prostate-specific antigen; Qmax, peak flow rate; PVR, post-void residual urine; IPSS, international prostate symptom score; QoL, quality of life Goal achievement for management of BPH-Kim et al. prostate volume, pre- and post-treatment uroflowmet- ric parameters, the presence of underlying diseases, the number of goals, and the sorts of goals were not signif- icantly different between higher and lower score groups (Table 3). Multivariate analysis revealed that pretreat- ment quality of life (OR = 8.6, 95% CI: 2.2-9.8) and improvement of quality of life (OR = 6.7, 95% CI: 1.9- 11.5) were independent predictive factors of patient-re- ported goal achievement (Table 4). The most common adverse event was low blood pressure (systolic pressure < 110 mmHg) in 11 patients, and dizziness and ejacula- tory disorder occurred in one patient each. DISCUSSION Although there is strong evidence for the benefit of combination therapy (α-blocker with 5-ARI), support- ed by several randomized, controlled trials, in terms of the symptom control, disease progression, and risk of BPH-related surgery,(11,12) monotherapy still constitutes the largest portion of medical therapy for BPH.(13,14- 16) Among the drugs used as a monotherapy, ≥-block- ers are the most common agents.(13,14-16) The availability of tamsulosin has been a major breakthrough for med- ical therapy of patients with BPH, due to comparable efficacy, fewer side effects, and a more optimal dose compared to previously existing α-blockers. With these advantages, monotherapy using α-blockers became more common after tamsulosin had been introduced to the clinical practice.(3) The efficacy of α-blockers, including tamsulosin, has been usually evaluated by uroflowmetry and specially designed questionnaires, such as IPSS and AUASS, in many BPH-related studies.(17-20) Although these eval- uation tools are well validated and objectively reflect the change of LUTS, they have limitations in evalua- tion of patients’ subjective satisfaction and initial goal achievement after treatment. Since BPH is a chronic and refractory disease and medical therapy became a standard treatment for most BPH patients with mild to moderate LUTS, adherence to and persistence with therapy are considered important factors for the success of the treatment.(5,21) Therefore, assessment and predic- tion of the patient-reported goal achievement can be a useful indicator to predict patients’ adherence to and persistence with medical therapy. Schoenfeld et al. reported that only about 40% of the patients with BPH who initiated α-blocker monothera- py continued medication for six months, and about one- third of the patients continued it for one year.(5) Howev- er, Shortridge et al. reported that 63.5% of the patients who initiated combination therapy with α-blockers and 5-ARIs persisted with their medications for more than four years.(21) This can be explained by the fact that the addition of 5-ARIs can be more helpful in improving LUTS subjectively as well as objectively. Currently, anticholinergic agents and phosphodiesterase type 5 in- hibitors are also available for medical therapy of BPH, and several studies have proven their efficacy.(1,22) In this situation, physicians should decide whether they will continue ≥-blocker monotherapy or add or change to other drugs after a short-term follow-up. Although several evaluating tools, such as uroflowmetry, IPSS, and voiding diary, can be helpful, patients’ treatment goals and subjective satisfaction may also have impor- tant roles in determining the strategy. As seen in this study, patients with BPH have various treatment goals, including not only voiding symptoms but also storage symptoms. However, the currently available BPH-re- lated evaluation tools, such as uroflowmetry and IPSS, may not reflect or assess patients’ main treatment goals. Continuing the same medical therapy, with only im- provements of uroflowmetric parameters and IPSS, re- gardless of patients’ treatment goals and/or subjective satisfaction, can lead to early discontinuation of medi- cal therapy and dropout of overall treatment. Nocturia improvement was the most common treat- ment goal (27.2%) in this study, followed by the weak urine stream improvement (22.4%). Seventy-eight pa- tients (43.6%) wanted to improve their storage symp- toms as initial treatment goals. This indicates that not a few patients with BPH want to improve their storage symptoms. Traditionally, tamsulosin was considered to provide more effect on voiding symptoms, but re- cent studies have shown that tamsulosin monotherapy also has effects on storage symptoms.(23,24) In this study, more than 70% of all patients achieved scores of 4 or 5, and among the patients whose initial goals were the storage symptom improvement, nearly 70% also achieved scores of 4 or 5. In addition, the mean storage subscore of IPSS was also significantly improved by the medication over time. This demonstrated that tam- sulosin monotherapy is effective for storage symptoms as well as for voiding symptoms in patients with BPH. Although only patients with a mild- to moderate-sized prostate were enrolled in the present study, this study confirmed that more than 70% of the patients with BPH were able to achieve their treatment goals (scores 4 or 5) after 12 weeks of tamsulosin monotherapy, regard- less of their primary treatment goals. In addition, every parameter, including the total IPSS, voiding subscore, storage subscore, QoL, Qmax, and PVR, was signif- icantly improved over time with tamsulosin mono- therapy. However, nearly 30% of the patients did not Table 4. Logistic regression analysis to determine the predictive factors of patient-reported goal achievement (higher score). Univariate analysis Multivariate analysis Odds ratio (95% CI) P value Odds ratio (95% CI) P value Pretreatment IPSS 0.8 (0.2-1.8) 0.284 0.8 (0.2-1. 9) 0.169 Pretreatment QoL 10.0 (2.5-10.1) 0.001 8.6 (2.2-9.8) 0.002 Duration of LUTS 1.0 (0.9-1.0) 0.372 1.0 (0.7-2.0) 0.155 Posttreatment IPSS 1.1 (1.0-1.1) 0.230 1.3 (0.8-2.5) 0.113 Δ IPSS (total) 1.0 (1.0-1.0) 0.859 1.0 (0.8-1.4) 0.967 Δ IPSS (voiding subscore) 1.0 (0.9-1. 2) 0.889 1.0 (0.5-1.1) 0.948 Δ IPSS (storage subscore) 0. 9 (0.8-0.9) 0.872 1.0 (0.6-2.0) 0.996 Δ QoL 7.6 (2.0-10.5) <0.001 6.7 (1.9-11.5) 0.001 Abbreviations: CI, confidence interval; IPSS, international prostate symptom score; QoL, quality of life; LUTS, lower urinary tract symptoms Goal achievement for management of BPH-Kim et al. Miscellaneus 389 Vol 16 No 04 July-August 2019 390 achieve their primary treatment goals, even with dose escalation, although their objective parameters, such as IPSS, Qmax, and PVR, improved compared to the pretreatment state. Based on several previous studies, a relatively low dose of tamsulosin (0.2 mg daily) was recommended as the standard regimen for the treatment of LUTS in Asian patients with BPH.(7,9,25) However, recent studies have shown that tamsulosin at 0.4 mg once daily can be more effective for the patients who do not respond to 0.2 mg once daily, especially for the improvement of Qmax without any increase in cardio- vascular events.(10,26) Therefore, all patients started tam- sulosin at 0.2 mg daily as the initial dose, and the dose was escalated to 0.4 mg after four weeks of treatment if the patients did not demonstrate their LUTS improve- ment in this study. By the analysis of risk factors for dose escalation, our study showed that patients with less improvement of Qmax and PVR could have higher risks for dose escalation. For the rest of the patients, who did not achieve their treatment goals (scores 1 or 2), a change in their treat- ment strategies needs to be considered, such as the addition or change of drugs, according to the state of their LUTS, even if their IPSS or uroflowmetric param- eters significantly improved; otherwise, there may be a higher risk of discontinuation of treatment. Thus, the patient-reported goal achievement can be used to de- termine a change or addition of other drugs after initial treatment of patients with BPH/LUTS. However, this evaluating tool also has disadvantages. The patient-re- ported goal achievement usually reflects changes of patients’ subjective symptoms. Although IPSS and uro- flowmetric parameters tend to correlate with changes of subjective symptoms, some patients may complain about less improvement of their voiding symptoms even if their IPSS, Qmax, and PVR were significantly improved, or vice versa. Therefore this patient-reported goal achievement cannot be used alone for the evalua- tion of objective changes in patients with BPH/LUTS. In addition, this study demonstrated that patients with higher pretreatment QoL and less improvement of QoL may have fewer chances of goal achievement after medical therapy. Therefore, close monitoring will be needed for these patients, and changing the treatment strategy should be considered. There are several limitations in this study. Although this study was performed prospectively based on mul- ti-institutional patient enrollment, a case-controlled tri- al or comparative study with other BPH drugs was not conducted. In addition, patients with only mild- to mod- erate-sized prostate were enrolled, even though this was not intended. A relatively high dropout rate due to a fol- low-up loss and the lack of long-term follow-up results, can also be limitations of this study. However, to the best of our knowledge, this is the first trial to assess the patient-reported goal achievement after the treatment with tamsulosin monotherapy for patients with BPH. It can be the base of a new evaluation tool to increase the adherence to and persistence with medical therapy for BPH/LUTS. Based on the results of this study, a larg- er, population-based, longer-term follow-up and rand- omized controlled trial with/without other BPH drugs will be needed for the future study. CONCLUSIONS In conclusion, medical therapy with tamsulosin is safe and effective as an initial treatment for patients with BPH. Nocturia and a weak urine stream are the most common lower urinary tract symptoms that patients with BPH want to be relieved by the treatment. More than 70% of our patients reported satisfactory goal achievement after 12 weeks of tamsulosin monother- apy, regardless of the patients’ treatment goals. This study demonstrated that the scores of pretreatment quality of life and improvement of quality of life can be important factors to predict the achievement of treat- ment goals. CONFLICT OF INTERESTS This work was conducted by the UROSTAR study group and supported by Astellas Korea. This research was also supported by the Basic Science Research Pro- gram through the National Research Foundation of Ko- rea (NRF), which is funded by the Ministry of Science, ICT & Future Planning (2015R1C1A1A01053509). REFERENCES 1. Van Asseldonk B, Barkin J, Elterman DS. Medical therapy for benign prostatic hyperplasia: a review. Can J Urol. 2015;22 Suppl 1:7-17. 2. Yamanishi T, Kaga K, Fuse M, Shibata C, Kamai T, Uchiyama T. Six-year follow up of silodosin monotherapy for the treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia: What are the factors for continuation or withdrawal? Int J Urol. 2015;22:1143-8. 3. Filson CP, Wei JT, Hollingsworth JM. Trends in medical management of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology. 2013;82:1386- 92. 4. Erickson BA, Lu X, Vaughan-Sarrazin M, Kreder KJ, Breyer BN, Cram P. Initial treatment of men with newly diagnosed lower urinary tract dysfunction in the Veterans Health Administration. Urology. 2014;83:304- 9. 5. Schoenfeld MJ, Shortridge EF, Gelwicks SC, Cui Z, Wong DG. Treatment patterns in alpha-blocker therapy for benign prostatic hyperplasia. Am J Mens Health. 2014;8:267- 72. 6. Abrams P, Schulman CC, Vaage S. Tamsulosin, a selective alpha 1c-adrenoceptor antagonist: a randomized, controlled trial in patients with benign prostatic 'obstruction' (symptomatic BPH). Br J Urol. 1995;76:325- 36. 7. Dunn CJ, Matheson A, Faulds DM. Tamsulosin: a review of its pharmacology and therapeutic efficacy in the management of lower urinary tract symptoms. Drugs Aging. 2002;19:135-61. 8. Lepor H. Phase III multicenter placebo- Goal achievement for management of BPH-Kim et al. Goal achievement for management of BPH-Kim et al. controlled study of tamsulosin in benign prostatic hyperplasia. Urology. 1998;51:892- 900. 9. Lyseng-Williamson KA, Jarvis B, Wagstaff AJ. Tamsulosin: an update of its role in the management of lower urinary tract symptoms. Drugs. 2002;62:135-67. 10. Chung JW, Choi SH, Kim BS, et al. Efficacy and tolerability of tamsulosin 0.4 mg in patients with symptomatic benign prostatic hyperplasia. Korean J Urol. 2011;52:479-84. 11. McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003;349:2387- 98. 12. Roehrborn CG, Barkin J, Siami P, et al. Clinical outcomes after combined therapy with dutasteride plus tamsulosin or either monotherapy in men with benign prostatic hyperplasia (BPH) by baseline characteristics: 4-year results from the randomized, double- blind Combination of Avodart and Tamsulosin (CombAT) trial. BJU Int. 2011;107:946-54. 13. Bishr M, Boehm K, Trudeau V, et al. Medical management of benign prostatic hyperplasia: Results from a population-based study. Can Urol Assoc J. 2016;10:55-9. 14. Cindolo L, Pirozzi L, Fanizza C, et al. Actual medical management of lower urinary tract symptoms related to benign prostatic hyperplasia: temporal trends of prescription and hospitalization rates over 5 years in a large population of Italian men. Int Urol Nephrol. 2014;46:695-701. 15. Lukacs B, Cornu JN, Aout M, et al. Management of lower urinary tract symptoms related to benign prostatic hyperplasia in real-life practice in france: a comprehensive population study. Eur Urol. 2013;64:493-501. 16. Hollingsworth JM, Hollenbeck BK, Daignault S, Kim SP, Wei JT. Differences in initial benign prostatic hyperplasia management between primary care physicians and urologists. J Urol. 2009;182:2410-4. 17. Roehrborn CG. Efficacy of alpha-adrenergic receptor blockers in the treatment of male lower urinary tract symptoms. Rev Urol. 2009;11:S1-8. 18. Wilt TJ, Howe RW, Rutks IR, MacDonald R. Terazosin for benign prostatic hyperplasia. Cochrane Database Syst Rev 2002:CD003851. 19. Wilt TJ, Mac Donald R, Rutks I. Tamsulosin for benign prostatic hyperplasia. Cochrane Database Syst Rev 2003:CD002081. 20. Moon KH, Song PH, Yang DY, et al. Efficacy and safety of the selective alpha1A- adrenoceptor blocker silodosin for severe lower urinary tract symptoms associated with benign prostatic hyperplasia: a prospective, single-open-label, multicenter study in Korea. Korean J Urol. 2014;55:335-40. 21. Shortridge E, Donatucci C, Donga P, Marcus M, Wade RL. Adherence and persistence patterns in medication use among men with lower urinary tract symptoms/benign prostatic hyperplasia. Am J Mens Health. 2017;11:164- 9. 22. Karami H, Hassanzadeh-Hadad A, Fallah- Karkan M. Comparing monotherapy with tadalafil or tamsulosin and their combination therapy in men with benign prostatic hyperplasia: a randomized clinical trial. Urol J. 2016;13:2920-6. 23. Ko K, Yang DY, Lee WK, et al. Effect of improvement in lower urinary tract symptoms on sexual function in men: tamsulosin monotherapy vs. combination therapy of tamsulosin and solifenacin. Korean J Urol. 2014;55:608-14. 24. Aikawa K, Kataoka M, Ogawa S, et al. Elucidation of the pattern of the onset of male lower urinary tract symptoms using cluster analysis: efficacy of tamsulosin in each symptom group. Urology. 2015;86:349-53. 25. Kawabe K, Ueno A, Takimoto Y, Aso Y, Kato H. Use of an alpha 1-blocker, YM617, in the treatment of benign prostatic hypertrophy. YM617 Clinical Study Group. J Urol. 1990;144:908-11;discussion 11-2. 26. Kim JJ, Han DH, Sung HH, Choo SH, Lee SW. Efficacy and tolerability of tamsulosin 0.4 mg in Asian patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia refractory to tamsulosin 0.2 mg: a randomized placebo controlled trial. Int J Urol. 2014;21:677-82. Miscellaneus 391